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4 <br /> APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> w' 445 N SAN JOAQUIN, PHONE (209)468-3420- <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM TE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby aside to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San JoaquiLgunty Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ee. � t J�e r�eG, /Job Address TA n J `j City L !1�'S.t Size/Acre age <br /> 11 ` f <br /> Owner's Name 7 X�_ & Address �SD�___G 1 2tr_ _ _ Phone <br /> I <br /> Contraclor L '11 S Address Q k•� O!c �C{ �License No. fCJ I Phone 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ 1 <br /> PUMP INSTALLATION._- SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private C1 Gravel Pack C1 Tracy. Type of Casing`: ' Specifications <br /> I'1 Public l:l Other (1 Delta Depth-of'Ge,6u Seal Type of Grout <br /> I I Irrigation Approx. Depth I I fastern Surf cd Seal Installed ttv ' <br /> Repair Work Done [Type of Pump Si e- H.P. f�Y State Work Done <br /> Well Destruction O Well Diameter sealing Material i Depth, <br /> Depth Filler Material i Depth , E <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other { <br /> Number of living units: Number of bedrooms <br /> Character of aoG to a depth of 3 fest: . Water table,depth <br /> SEPTIC TANK O Type achy No. Compartments <br /> PKG. TREATMENT PLT.07 Method of•DiW- sal ; <br /> Distance to rte Well oundation Property Line 1 <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth /eal NumberSUMPS L) Distance to nearest: Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county + <br /> Home owner ensed nt's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an son in wch tanner as to become wN to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies folbwi :"I c fy that in perform s f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion of Calif <br /> Thea plicant rail 1de. <br /> Sig Title: A4Y/, Date: _ 'a 01- <br /> FOR <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data � L Area <br /> Pit or Grout Inspection by Date Final Inspection byI 1A <br /> Da[s <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services I <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEFK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. i <br /> + EH1 <br /> 7-24 tltEV,1/M 51 <br /> EH 14-28 r O <br />